Volunteer
Application Form
Name______Male ____ Female_____
(First) (Last)
Phone ______
(Home #) (Work #)
Address ______
(Street) (City) (State) (Zip)
Drivers License #______State______
Social Security #______
E-Mail Address ______
VOLUNTEER & EMPLOYMENT INFORMATION
1) Organization ______Phone______
Address______State______Zip ______
Job title ______Contact Person ______
Job Responsibilities ______
______
Approximate Dates Employed ______
2) Organization ______Phone______
Address ______State______Zip ______
Job title ______Contact Person ______
Job Responsibilities ______
______
Approximate Dates Employed ______
May we contact the above employers? _____Yes _____ No
If No, please explain why. ______
REFERENCES (If different from above)
Please list two people that you have known for at least one year.
One should be professional (minister, teacher, boss, etc)
1) Name Phone ______
Occupation Address ______
2) Name Phone ______
Occupation Address ______
How did you hear about EMARC? ______
Please describe any experience you have with people with developmental disabilities:
Please list any special skills, hobbies or interests you may have
Do you speak any foreign languages? If so, please list:
I am a Red Cross certified lifeguard:____ Yes ____ No
I am CPR / First Aid certified:____ Yes ____ No
If you will be receiving academic or community service credit, please describe your requirements:
Do you have any physical or medical conditions which may affect volunteer work?
___ Yes ___ No If yes, please describe:
When are you available to volunteer?
____ Weekdays ____ Weekday Evenings ____ Weekends ____ Weekend Evenings
Please check all programs for which you would be willing to volunteer:
(this does not commit you to a program, but gives us an idea of your interests!)
GENERAL
_____Office Help_____Computer training_____ Maintenance
_____ Fundraising_____Public Relations_____ Companion for group-
_____Work/Training programs_____Arts programs home residents
_____ Other: ______
RECREATION
_____ Youth_____ Arts_____Special Olympics
_____ Teen_____ Swimming_____ Social / Community trips
_____ Adults_____ Sports / Fitness_____ Other ______
*Some programs require a commitment for entire session, generally 4-10 weeks.
You must provide your own transportation to off-site programs.
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Volunteer Agreement
I, the undersigned, represent and warrant that, to the best of my knowledge and belief, I am physically and mentally able to participate as a volunteer in EMARC programs. I agree to provide my own transportation to and from all programs and to notify a program supervisor immediately if I am unable to attend a program.
With the submission of this form I certify that all information is a true and complete statement of the facts and answers required herein without omission.
The EMARC may contact all previous employers, schools, and references for full information except as I have stated otherwise on this form. By this form, I hereby authorize and direct employers, schools, and references, named above to give any information regarding my employment or education.
If selected, I give my permission to include my name and/or picture in all Arc of East Middlesex promotional material, newspapers, T.V., radio, brochures, videos, etc.
____ Yes ____ No
SIGNATURE ______DATE ______
We must have your signature if you wish to be considered for volunteer positions. Thank you.
PARENT/GUARDIAN SIGNATURE ______DATE ______
Required If under 18 years of age
If you are over the age of 18, you will be required to complete a Criminal Offender Record Information (CORI) and a Disabled Person Protection Commission (DPPC) check.
Please remit all forms to:
Volunteer Coordinator
EMARC, Inc
26 Princess Street, Wakefield, MA
Email:
Website:
Phone: (781) 587-2270
Fax: (781) 587-2271
VolunteerMedical
Release Form
EMARC, Inc
26 Princess Street, Wakefield, MA
Email:
Website:
Phone: (781) 587-2270
Fax: (781) 587-2271
If a medical emergency should arise during participation in any EMARC program and I am not able to give my consent, for whatever reason, I authorize the organizers to take whatever measures are necessary and which it deems advisable to protect my health and well being, including but not limited to first aid, ambulance transport, and/or hospitalization.
I for myself, my heirs, executors and administrators, waive and release any and all claims for damages I may have against the sponsors, organizers and any individuals associated with the event, their successors and assigns and will hold them harmless for any and all injuries suffered in connection with EMARC.
I have read and fully understand the provisions of the above release. I understand that, through my signature of this release form, I am agreeing to the above provisions on my own behalf or on behalf of my child.
______
Volunteer SignatureDate
______
Parental Signature (for volunteers under 18)Date
Medical Information:
Please note any allergies you may have and resulting reactions: ______
______
______
In the event of an emergency, please contact (must be a different number than home phone):
______
(Name) (Phone #, including area code)(Relation to volunteer)
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